Business Models of Ehealth Interventions to Support Informal Caregivers of People with Dementia in the Netherlands: Analysis of Case Studies

JMIR AGING Christie et al

Original Paper Business Models of eHealth Interventions to Support Informal Caregivers of People With Dementia in the Netherlands: Analysis of Case Studies

Hannah Liane Christie1, BSc, MSc, PhD; Lizzy Mitzy Maria Boots1, BSc, MSc, PhD; Ivo Hermans2, BA, MSc; Mark Govers3, BSc, MSc, PhD; Huibert Johannes Tange4, BSc, MSc, MD, PhD; Frans Rochus Josef Verhey1, BSc, MSc, MD, PhD; Majolein de Vugt1, BSc, MSc, PhD 1Alzheimer Centrum Limburg, Maastricht University, Maastricht, Netherlands 2Betawerk, Heerlen, Netherlands 3Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands 4Department of Family Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands

Corresponding Author: Hannah Liane Christie, BSc, MSc, PhD Alzheimer Centrum Limburg Maastricht University Postbus 616 Maastricht, 6200 MD Netherlands Phone: 31 456 21 30 78 Email: [email protected]

Abstract

Background: In academic research contexts, eHealth interventions for caregivers of people with dementia have shown ample evidence of effectiveness. However, they are rarely implemented in practice, and much can be learned from their counterparts (commercial, governmental, or other origins) that are already being used in practice. Objective: This study aims to examine a sample of case studies of eHealth interventions to support informal caregivers of people with dementia that are currently used in the Netherlands; to investigate what strategies are used to ensure the desirability, feasibility, viability, and sustainability of the interventions; and to apply the lessons learned from this practical, commercial implementation perspective to academically developed eHealth interventions for caregivers of people with dementia. Methods: In step 1, experts (N=483) in the fields of dementia and eHealth were contacted and asked to recommend interventions that met the following criteria: delivered via the internet; suitable for informal caregivers of people with dementia; accessible in the Netherlands, either in Dutch or in English; and used in practice. The contacted experts were academics working on dementia and psychosocial innovations, industry professionals from eHealth software companies, clinicians, patient organizations, and people with dementia and their caregivers. In step 2, contact persons from the suggested eHealth interventions participated in a semistructured telephone interview. The results were analyzed using a multiple case study methodology. Results: In total, the response rate was 7.5% (36/483), and 21 eHealth interventions for caregivers of people with dementia were recommended. Furthermore, 43% (9/21) of the interventions met all 4 criteria and were included in the sample for the case study analysis. Of these 9 interventions, 4 were found to have developed sustainable business models and 5 were implemented in a more exploratory manner and relied on research grants to varying extents, although some had also developed preliminary business models. Conclusions: These findings suggest that the desirability, feasibility, and viability of eHealth interventions for caregivers of people with dementia are linked to their integration into larger structures, their ownership and support of content internally, their development of information and communication technology services externally, and their offer of fixed, low pricing. The origin of the case studies was also important, as eHealth interventions that had originated in an academic research context less reliably found their way to sustainable implementation. In addition, careful selection of digital transformation strategies, more intersectoral cooperation, and more funding for implementation and business modeling research are recommended to help future developers bring eHealth interventions for caregivers of people with dementia into practice.

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(JMIR Aging 2021;4(2):e24724) doi: 10.2196/24724

KEYWORDS eHealth; dementia; caregiving; implementation; business modeling

crucial in the context of the current COVID-19 pandemic. A Introduction recent article in The Lancet on the impact of COVID-19 on Background people with dementia and their caregivers advised care professionals to organize psychoeducation, self-management, A recent systematic review [1] showed that very few and consultations for dementia caregivers on the web [22]. A evidence-based eHealth interventions for informal caregivers survey of 1000 Dutch caregivers of people with dementia by of people with dementia have been implemented in practice. Alzheimer Netherlands showed that the COVID-19 pandemic eHealth, defined by the World Health Organization as ªthe use has resulted in the cancelation of day care services for people of information and communication technologies (ICT) for with dementia as well as insufficient professional and social healthº [2], has the potential to help many people living with support. Caregivers mentioned digital contacts, such as video physical and mental health issues, including informal caregivers chatting or WhatsApp messaging, as one of the solutions that of people with dementia. Informal care constitutes a significant currently helps them the most [23]. part of dementia care [3,4] and can include helping with household chores, running errands, facilitating social Unfortunately, the implementation of eHealth is often engagement, and coordinating professional care. In the fragmented and short lived and lacks sufficient vision and Netherlands, it has been estimated that approximately 10% of strategy [24]. In addition to the eHealth interventions being the 16 million inhabitants offer some form of informal care [5], developed in an academic research context, there is also eHealth whereas an estimated 320,000 informal caregivers provide care being developed outside of academia, for instance, by industry specifically for people with dementia [6]. However, informal and health care organizations [25], from which much can be caregivers have also been shown to experience physical and learned to aid the implementation of eHealth interventions for psychological complaints as a result of this caregiving process caregivers of people with dementia originating from the research [7]. Given the fact that the current worldwide prevalence of context. For the most part, these nonacademic interventions are dementia (50 million people) is expected to triple by 2050 [8] not included in the search strategies used in systematic reviews, and the health care systems' increasing reliance on informal as their development and testing are usually not published in care [9], it is important to support these informal caregivers of academic journals. people with dementia. Previous research has shown that eHealth A useful framework to explore the factors that contribute to the interventions to support these caregivers have been effective in (financial) sustainability of nonacademic interventions is the improving caregiver outcomes, such as self-efficacy, Business Model Canvas [26]. The Business Model Canvas is competence, and knowledge about dementia, and in reducing an established framework intended to aid in the development depressive symptoms [10-18]. and mapping of new and existing business models by In general, eHealth has many potential benefits compared with demonstrating the product or service's value proposition, key more traditional face-to-face interventions: it is relatively easy activities, key resources, key partners, cost structure, customer to implement on a larger scale; it has the potential to reach users relationships, distribution channels, and revenue. The Business from various socioeconomic and demographic backgrounds; Model Canvas has previously been used to map business models and it can include extensive personalization, instant delivery, for eHealth interventions [27-29]. Recently, developers grouped and real-time feedback [19,20]. There is preliminary evidence segments of the Business Model Canvas to construct blocks of that web-based tools might be at least as effective as face-to-face desirability, feasibility, and viability [30]. Figure 1 (adapted interventions in delivering psychiatric support [21], although from the study by Osterwalder and Pigneur [26]) illustrates how more research is needed. eHealth as a potential solution to the 9 elements of the Business Model Canvas can be grouped facilitate access to dementia caregiving support is even more into these factors.

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Figure 1. Desirability, feasibility, and viability of the business models.

(1) delivered via the internet; (2) suitable for informal caregivers Objectives of people with dementia, (3) available in the Netherlands, either This study aims to explore how lessons learned from in Dutch or in English; and (4) used in practice. The aim was interventions currently being used in practice could aid the to receive recommendations for between 5 and 10 interventions implementation of evidence-based interventions for informal that met all criteria, as this would achieve data saturation but caregivers of people with dementia. To accomplish this, this still be a small enough number to analyze in depth. The study had 3 aims: (1) to examine a sample of case studies of suggested interventions were not meant to serve as an exhaustive eHealth interventions to support informal caregivers of people overview of all available eHealth interventions for caregivers with dementia that are currently used in the Netherlands; (2) to of people with dementia in the Netherlands. Rather, they are a investigate what strategies are used to ensure the desirability, sample of this type of intervention, which was defined using a feasibility, viability, and sustainability of the interventions; and systematic approach. (3) to formulate lessons learned to facilitate the implementation of future eHealth interventions. Step 2: Qualitative Interviews With eHealth Intervention Providers Methods After receiving these recommendations, the researchers reached out to the interventions' contact people with an invitation to Study Design participate in a telephone interview about their experiences with Step 1: Identifying eHealth Interventions for Caregivers their intervention's implementation. This study used a multiple case study methodology for the analysis. This methodology was of People With Dementia chosen for its ability to qualitatively explore complex Contacting Experts phenomena within their contexts and explore differences within, First, to acquire a sample of eHealth interventions to support as well as between, cases [31]. The focus is on collecting caregivers of people with dementia that are being used in in-depth data from a limited number of cases. To do this, this practice, experts (N=483) in the fields of eHealth, dementia, study made use of semistructured interviews because of their and caregiving were contacted via email. fit with the aim of collecting qualitative, open-ended data, using which it is possible to delve deeply into the thoughts and Inclusion Criteria opinions of the participants. The semistructured interviews The experts were asked to provide the names of interventions consisted of 9 questions. The interview guide can be found in that met the following 4 inclusion criteria: eHealth intervention Multimedia Appendix 1. It was constructed by the authors to

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explore the desirability, feasibility, and viability of the included and 1 psychiatrist). Regarding the significant difference in the eHealth cases based on the Business Model Canvas framework number of emails sent per subsample, the possibility of [26]. To do this, the interview guide asks the participants approaching researchers via the INTERDEM network questions based on each of the 3 main domains. In addition, (consisting of 330 mailing list contacts) was associated with a data were collected on the description, current use, and business much lower response rate, as it was a general mailing instead model of the interventions. of a targeted personal mailing. Third, 15 dementia caregivers were asked to provide examples of interventions that met the 4 Sample inclusion criteria during a dementia client panel meeting at First, emails with an invitation to provide examples of Maastricht University. The caregivers were part of the interventions meeting the 4 inclusion criteria were sent to a Maastricht University's dementia client panel. Finally, a notice diverse sample of experts. Experts (n=330) in the academic was placed on the social media channels (Twitter, Facebook, field were approached via the INTERDEM mailing list. and LinkedIn) of the Nederlandse Vereniging voor INTERDEM is an international research network that focuses Neuropsychologie (NVN; the Dutch Association for on psychological care for dementia. Second, 4 emails were sent Neuropsychology), which was clicked on 120 times across to experts in the industry (employees of small- and channels, according to NVN. medium-sized enterprises, which usually consist of <250 employees), 10 emails were sent to representatives from Table 1 provides an overview of the backgrounds of the included dementia and caregiver patient organizations, and 4 emails were interview participants whose interventions met all 4 criteria and sent to clinicians in the field of dementia care (3 psychologists who could be contacted for an interview (the Results section provides more details on intervention inclusion).

Table 1. Interview participants' background. Case study Intervention name Background interview participant 1 Partner in Balance Academia 2 STAR eLearning Academia 3 OZOverbindzorg Industry 4 Carenzorgt Industry 5 (redacted) Clinic (psychologist) 6 Thinkability Academia 7 DementieNL (and Myinlife) Patient organization 8 (redacted) Clinic (psychologist) 9 Nachtrust bij Dementie Academia

Data Analysis Data Collection The data were analyzed using a qualitative, multiple case study First, emails with an invitation to provide examples of methodology [32]. HLC conducted the initial analysis using the interventions that met the 4 inclusion criteria were sent to a extraction table and interview transcripts. The first phase of this diverse sample of experts (N=483). Each of these experts was analysis involved examining the individual cases to understand known to the research team through their own professional each intervention, its implementation trajectory, and its business networks. Each email was sent once. A total of 15 dementia model. Here, the focus was on explanation building [33], where caregivers were asked face-to-face to provide examples during the narratives from the interviews were combined with the data a dementia client panel meeting at Maastricht University. The from the extraction table to map each sampled intervention in notice on the NVN was placed once. detail. Once interventions were identified, the providers of these The second phase involved comparing cases with each other to interventions were interviewed over the telephone. For the 9 identify common and differential characteristics. To do this, the included case studies, interview data were collected using the interview transcripts were analyzed across cases by assigning interview guide in Multimedia Appendix 1. These data were codes (desirability, feasibility, and viability) to respondents' collected between December 2018 and June 2019. In total, 9 replies that provided more information on these topics. This interviews were conducted via telephone and transcribed guided an explanation of which characteristics could contribute verbatim. On average, the interviews lasted for 25 minutes (SD to intervention desirability, feasibility, and viability across cases. 11.9). Data were also collected on the description, current use, and business model of the interventions and are represented in In the third phase, the results of this initial analysis were an extraction table (refer to the Results section). discussed with HLC, LMMB, HJT, MG, and MEDV in a consensus meeting, where differences in interpretation were resolved and external validity was supported. In particular, the authors discussed the value propositions (ie, the elements of the

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service or product that are intended to make the intervention more attractive to customers) of the included cases; their Results common characteristics in terms of desirability, feasibility, and Overview viability; and their respective implementation phases and business models. Finally, a member check (where participants The first section provides an overview of all the interventions were sent the interview transcript for approval) [34] served to suggested by the contacted experts and describes the included support the internal validity of the analysis. case studies. In the second section, the following characteristics of the included case studies are examined: (1) desirability, Ethics feasibility, and viability of the interventions; (2) findings on the This study did not fall under the scope of the Medical Research sustainability of their business models; and (3) lessons learned Involving Human Subjects Act. Therefore, ethical approval by from the respondents. Maastricht University's institutional review board was not Interventions Suggested by Experts required. The respondents were verbally informed of the purpose of the study before the interview and gave their consent to the Overview of Interventions interview being audio recorded and analyzed anonymously. A total of 36 responses were received (14 from researchers, 10 However, it was not possible to guarantee total anonymity from patient organizations, 3 from industry professionals, 4 because the interventions themselves were discussed by name. from clients, and 5 from clinicians), resulting in a response rate Therefore, it was requested that names of interventions not be of 7.5% (36/483). Although this response rate is rather low, it used for case studies 5 and 8. The participants consented to this, was deemed well suited for the described purpose of gathering and a member check was conducted. Through this member a limited, nonexhaustive sample of cases to be analyzed in depth check, all participants (including the participants involved in by multiple case study methodology. A total of 21 interventions case studies 5 and 8) approved (in writing) the information in were nominated to be part of the sample. Some experts the transcripts being used in this study (with the exception of suggested multiple interventions, whereas others did not suggest the names of case studies 5 and 8). any interventions. Overall, 11 interventions were excluded based on the 4 criteria described earlier. A final intervention was excluded because nobody could be contacted for the interview, resulting in insufficient data for a case study analysis. Figure 2 depicts a flowchart of the case study inclusion.

Figure 2. Flowchart of case study inclusion.

2 provides the names, number of nominations, description, and Included Case Studies current use of the included case studies. DementieNL and In total, 9 interventions met all 4 criteria and could be contacted Myinlife are discussed together, as Myinlife has been integrated for interviews, resulting in their inclusion as case studies. Table into the broader DementieNL platform.

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Table 2. Extraction table. Case study Intervention name Nominations Description Current use (January Pricing 2020) 1 Partner in Balance 5 Web-based intervention to support care- Available on the web €200 (US $243.28) per givers and promote self-management, with (only in participating caregiver per year coach (a formal caregiver), for informal areas) caregivers (academic origin) 2 STAR eLearning 1 Web-based intervention to improve demen- Available on the web €25 (US $30.41) per caregiv- tia caregiving skills for both formal and (after approval) er per year informal caregivers (academic origin) 3 OZOverbindzorg 1 Web-based platform to connect care part- Available on the web Health insurer and munici- ners, for informal caregivers to invite for- (only in participating pality jointly pay €1 (US mal caregivers (nonacademic origin) regions or municipali- $1.22) per user (calculated ties) over region) 4 Carenzorgt 5 Web-based platform to facilitate the orga- Available on the web Free nization of care for people with dementia, for both formal and informal caregivers (nonacademic origin) 5 {redacted} 4 Web-based intervention to provide tips for Available on the web Free if the person with de- caring for a person with dementia, with a mentia is registered with the coach, for both formal and informal care- care organization (name givers (partial academic origin) redacted), €500 (US $608.20) for course if not registered with the care organization (name redacted), and currently not accepting new applicants because of lack of resources 6 Thinkability 1 Web-based cognitive stimulation therapy Available £4.99 (US $7.06) in App intervention to improve quality of life, for Store and Google Play both people with dementia and informal caregivers (academic origin) 7 DementieNL (and 7 Web-based platform for dementia care Available on the web Free Myinlife) (included caregiver test, web-based dementia training, and ªask an expertº), for informal caregivers. Includes Myinlife, a web- based platform to facilitate the organization of care for people with dementia (partial academic origin) 8 {redacted} 1 Web-based platform that contains both Available on the web Free if caregiver is a client internal and external modules informing with Innovate (organiza- about dementia care, for formal and infor- tion), otherwise €10 (US mal caregivers (partial academic origin) $12.16) 9 Nachtrust bij Demen- 1 Web-based intervention to inform about Web-based platform, No pricing model (research tie night-time unrest in a person with demen- although coaching not project) tia and provide nonpharmaceutical tips, currently available be- for informal caregivers (academic origin) cause of lack of resources

feasibility, and viability characteristics of their interventions. Case Study Characteristics The table synthesizes these responses across case studies and Strategies Relating to Case Study Desirability, groups them according to the categories of desirability, Feasibility, and Viability feasibility, and viability. The characteristics are first presented in the table and described in more detail in the following Overview sections. Table 3 provides an overview of the interview respondents' answers to the questions about the current desirability,

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Table 3. Common case study characteristics, as reported in case study interviews. Common characteristics Partner in STAR OZOverbind- Caren- (redacted) Thinkability DementieNL (redacted) Nachtrust bij Balance eLearning zorg zorgt (and Myinlife) Dementie Desirability

Targeted user is most- ✓a ✓ ✓ ✓ ✓ ly caregiver Low price (see Table ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 2 for prices) Incorporated into ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ larger systems Up-to-date content ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Community creation ✓ ✓ ✓ ✓ ✓ ✓ Feasibility Self-ownership of ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ content Information and com- ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ munication technology platform supplied by third party Helpdesk and imple- ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ mentation support services supplied internally Limited internal mar- ✓ ✓ ✓ ✓ ✓ ✓ ✓ keting capabilities Viability Variable price for dif- ✓ ✓ ferent packages of services, for a fixed amount of time, for caregivers, for health care organizations, and for municipalities and health insurers Fixed price for access ✓ ✓ ✓ ✓ to information and services Increasing the attrac- ✓ ✓ tiveness of a larger health care platform Supplying information ✓ ✓ and services at no cost

aCharacteristic present in the case study. exist. It should be used that way. That the caregiver Desirability can initiate, but also the health care professional, The interventions included as case studies were targeted at and they both have need of that knowledge. informal caregivers of people with dementia. However, many [Respondent case study 5] case studies have also decided to target formal care by Interestingly, even in blended interventions where the guidance developing aspects of their platforms for health care of a health care professional is necessary, the eHealth platform professionals: was not targeted at these care professionals. In all cases, there Well you notice that there is a lot of demand from remained a primary focus on the needs of informal caregivers. health care professionals. So people say ªGosh, we Next, a common characteristic was the overall relatively low find this interestingº and recommend it to their pricing of eHealth (Table 2). The eHealth platform was often clients, to know what is going on and what they are also incorporated in larger systems. These could be web-based getting, before they give advice about which modules platforms, such as Carenzorgt (Nedap) and case study 6

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(redacted), or offline systems, such as DementieNL and Myinlife demographic is not always comfortable with solutions such as (Alzheimer Netherlands) and STAR eLearning (Dementia PayPal. Meeting Centres): Viability I think an advantage of our situation at the university In total, 4 different types of viability strategies were observed is that we have a national network of meeting centres. in 9 cases. Most interventions (Partner in Balance, STAR There are already 160 of them in the Netherlands, eLearning, OZOverbindzorg, and case study 6) opted to vary which come together once a year, where we inform their prices for different subscription packages of services. They them about all kinds of interesting developments for did this in terms of both content and volume. Other case studies them, also the STAR course. [Respondent STAR] (such as Thinkability) offered their eHealth interventions on This integration significantly increased the visibility of the case the web for a fixed price, after which the buyer had access to study and provided a supportive structure. All case studies the service indefinitely. Indeed, in this sample, Thinkability is mentioned the time and effort needed to keep eHealth content the only intervention whose cost structure was centered around relevant and up-to-date as a significant but necessary drain on direct download from the internet by the caregiver, without resources. Finally, many case studies have emphasized the mediation by an existing health care system. STAR eLearning importance of creating a community around the eHealth and the case study 6 modules are also available for the caregiver intervention. These communities were places where caregivers to access without a health care organization, although these could contact each other and share experiences about the eHealth modules are at least partly integrated into existing dementia intervention and dementia caregiving in general. These care systems, such as dementia meeting centers and a care communities sometimes took place on a designated forum on organization, respectively. Finally, some cases, such as the intervention website or via social media channels, such as Carenzorgt and DementieNL (and Myinlife), made no revenue a closed Facebook group. but instead increased the attractiveness of a larger health care platform or organization: Feasibility Most of the cases were developed by groups with specific We mainly make software for health care institutions, expertise in dementia and caregiving. Most of the studied cases especially in elderly care and disabled care and a bit chose to develop the content themselves (and hence owned this in mental health care. Nine years ago, we thought it content) while hiring an external party to help build and maintain was important to involve the client's family in the the web-based platform. Often, it was the expertise party who process. This also helps health care professionals do ran a helpdesk and support service for users, forwarding better. So we said, we will make this platform. We technical questions to the hired software party. In this case, think it's important for the entire infrastructure that these support tasks were either part of a research position at a we have this and offer it for free. [Respondent university or on a volunteer basis. Most of the studied cases Carenzorgt] were limited in terms of marketing. In general, their aim seemed Finally, other case studies (such as DementieNL and Myinlife) to be to sustain eHealth rather than scale it up: existed to supply information and services at no cost to caregivers and were financed in large part through sponsorships. So when regions report that this sounds good, they also want this, then we start. But we do not actively Sustainability of Business Models search for regions where we can implement It was clear that although all the case studies were included OZOverbindzorg. We do not think that is societally because of their use in practice, the levels of use varied strongly. appropriate. So no, they come to ask us. [Respondent Table 4 lists the implementation phases and business models OZOverbindzorg] of the included case studies. The descriptions of these business This is because none of the cases aimed to make a profit. models as well as the implementation phase of the intervention Payment was mentioned as a barrier multiple times, with are based on the responses of the interview participants during respondents warning that setting up a secure payment system the case study interviews. The descriptions also contain takes considerable time and effort and that their older information on how the interventions are financed (in brackets).

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Table 4. Implementation phase and business models of the case studies. Implementation of case studies Business models Sustainable implementation OZOverbindzorg Subscription (paid by municipalities and health insurers) Carenzorgt Incentive (free to increase attractiveness of the larger platform) STAR eLearning Subscription (paid individually by the caregiver or in bulk by the organization, with varying options) DementieNL (and Myinlife) Sponsorship (free through sponsor support to Alzheimer Netherlands) Developing implementation Partner in Balance Grants, with a plan for subscription model (paid by municipalities and organizations) Thinkability Combination of fixed price and grants (one-time download from App Store and Google Play) Case study 6 Combination of fixed price and grants (paid individually by the caregiver or in bulk by the organization, with varying options) for nonorganization members, free if organization member Case study 5 Fixed cost (paid individually by the caregiver or in bulk by the organization, with varying options) for nonorganization members, free if organization member Nachtrust bij Dementie Grants (research project)

developers based on their experiences in bringing eHealth for Lessons From Respondents dementia caregivers into practice. Textbox 1 lists the lessons During the interviews, respondents from each case study were learned, as reported by the case study interviews. asked to formulate recommendations for future eHealth Textbox 1. Lessons learned by respondents.

• Make use of an innovation consortium by involving health care providers, financers, users, and technical developers in every phase of development • Provide a good fit with the intervention's implementation context • Ensure long-lasting marketing • Start implementing and learning, rather than waiting and perfecting designs. In other words, start small and develop the interventions further based on user feedback

• Bigger implementation budgets are crucial • Commercial collaboration is a big help (eg, marketing firms, information and communication technology companies, and sales and legal experts) • Health insurer collaboration is beneficial to sustainable implementation through its potential to determine priorities and develop relevant and sustainable interventions

• Involve users in the whole process as much as possible, for example, through co-design and cocreation

Discussion Design of eHealth Business Models First, the design of the proposed core business model is based Principal Findings on the desirability, feasibility, and viability characteristics of This study identified a sample of 9 case studies on the the case studies. The first key element of this design concerns implementation, use, and development of eHealth interventions its desirability, specifically by incorporating eHealth for caregivers of people with dementia that are currently used interventions into larger, pre-existing health care contexts. The in practice in the Netherlands. The main findings from case study interview respondents mentioned that the fit of the interviews with representatives of these interventions showed interventions with existing organizational goals and contexts that 4 cases were found to have developed sustainable business was an important part of intervention desirability, separately models (ie, business models that generate revenue for the upkeep from any financial considerations. This is in line with previous and development of the intervention in the future). Overall, 5 studies on the implementation of eHealth interventions in other cases were implemented in a more exploratory manner and populations [35-37]. Indeed, contextual integration is an relied on research grants to varying extents, although some had important part of many established implementation frameworks, also developed preliminary business models. These findings including the Consolidated Framework for Implementation have led to the following recommendations for the design, the Research [38], Normalization Process Theory [39], and Open implementing team, and the suggested implementation strategies Innovation Theory [40]. of a core business model to help achieve the long-term The second key element of the proposed design concerns the implementation of eHealth interventions for caregivers of people similarities in the feasibility characteristics of the interventions. with dementia. The case studies tend to supply the dementia-specific content

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and helpdesk of the eHealth internally, whereas ICT and regard, this research underscores the need for more software services are outsourced to an external party that does implementation funding and research into the business modeling not own the content. In other words, the execution of these of evidence-based eHealth interventions [45,46]. ICT-related key activities is shifted to key partners. Previous In addition, more traditional research methods such as research has discussed the frequent outsourcing of services in randomized controlled trials are not time efficient or resource ICT [41] and emphasized the importance of trust between efficient and can impede researchers from reaching this involved parties in constructing these types of business models implementation stage [47]. The use of alternative, more flexible in eHealth [42]. These studies recommend knowledge sharing research designs, with faster iteration and earlier consideration experiences between the involved parties to foster trust, which of implementation determinants, could also help overcome this has been shown to help attain the benefits of outsourcing. barrier [48]. The benefits of sustainably implementing these Finally, the third key element of the proposed core model's academically developed eHealth interventions for caregivers of design pertains to its viability. A prevalent, sustainable cost people with dementia include avoiding squandering public structure is a fixed price for access to the intervention's money on failed implementations, better allocation of research information or services, which is paid by health care resources, and realizing the anticipated benefits for intended organizations. Another viable option for sustainability is users [49]. integration into a larger platform that sponsors the eHealth intervention, so no cost is charged from the caregiver. Again, eHealth Implementation Strategy it is clear that when considering the viability of these business Finally, an important question is, ªWhich strategies can help models, viewing the intervention within its health care context bring the proposed core business model into practice, and keep can facilitate its sustainable implementation [28]. This pertains it in practice?º Here, it may be useful to gain inspiration from to both the desirability of the intervention through its contextual business. For instance, digital transformation strategies are a fit and its financial viability through its use of revenue structures key part of bringing business models into practice by already in place. A good example of the successful application coordinating and prioritizing the many different aspects of of these 3 core model elements is OZOverbindzorg, which digital transformation [50]. Previous research on digital makes use of fixed price, low cost, and equal buy-ins from transformation strategies has pointed to the importance of collaborations between health insurers and municipalities per community creation in generating revenue through freemium participating region. This is in line with the principles discussed business models [51]. A freemium business model involves in previous research, namely, that costs and benefits should be ªoffering a basic version of the product or service free of charge, balanced between parties in eHealth, and one party should not while the premium version is made available against additional disproportionally benefit from something that is financed by paymentº [52]. Community creation refers to forming and the other party [43]. Here, the benefits are shared between the maintaining a community of intervention users who are in care organizations and community well-being; therefore, it is contact with each other through the intervention. fair that both equally contribute to the costs. Although there was no clear example of a freemium business Implementing Team model in this sample, community creation was an important part of many of the included case studies, even more so among Next, the main finding of this study concerns the question of those grouped in the sustainable implementation category. who is implementing these interventions. In this study, case Future research could test the proposed core model for external studies that did not originate in an academic research context validity and investigate the effectiveness of community creation more successfully achieved sustainable implementation, as part of a digital implementation strategy to increase the compared with the case studies that originated in an academic sustainability of eHealth interventions for caregivers of people research context. There is a noticeable absence of eHealth with dementia. Here too, alternative, flexible research designs interventions that originated as research projects in the offer possibilities for comparing and evaluating innovative identified, sustainable financing models used in practice. Indeed, implementation strategies [53]. Figure 3 depicts the proposed most academic interventions are constrained by expiring funding core business model. [44], and integration within existing structures is crucial. In this

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Figure 3. Success factors of the eHealth interventions for caregivers of people with dementia.

aspects of their own interventions and minimize difficulties in Strengths and Limitations the responses about their learned lessons. A final limitation This study helps alleviate a significant problem in the field of concerns the fact that this study did not guarantee respondents' eHealth interventions for caregivers of people with dementia: total anonymity; because interventions would be referred to by a lack of information on financially viable, long-term name (unless respondents explicitly requested otherwise, as in implementation trajectories. By taking an intersectoral case studies 5 and 8), the intervention could conceivably be perspective and learning from interventions already being used linked to one of a few possible intervention respondents. This in practice, this research is broader than most studies, which was discussed before the interview and agreed to by the are often limited to studying interventions developed in an respondents, who also provided a member check, approving the academic research context. This approach made use of a interview transcript. This lack of total anonymity could have systematic method to select interventions for case studies based impeded respondents from discussing more sensitive on expert opinion and predefined criteria. Finally, it is important implementation topics candidly, out of fear of (social) to note the timeliness of this study. It is fair to say that in the repercussions from collaborators. Another possible consequence context of the COVID-19 pandemic, there is a greater need than of this lack of anonymity is that the eHealth contact persons ever to provide caregivers of people with dementia with good might not have wanted to share important details of their web-based support options. The findings of this study provide business plans to remain competitive. concrete implementation lessons to aid eHealth developers who wish to implement and scale up eHealth interventions to support Conclusions caregivers of people with dementia at a distance. Case studies that did not originate from an academic research context seemed to achieve more sustainability, whereas case This study has several limitations. First, there is a possibility studies from academic research contexts experienced barriers of selection bias, as the definition of this sample required to financial independence from research grants. Examining the responses from the authors' own dementia and eHealth common and differential characteristics of these case studies networks. As a result, the first possible bias is toward experts resulted in the proposal of a core business model for eHealth from academia, who are overrepresented in this sample. Second, interventions for caregivers of people with dementia, derived there is likely a higher than average degree of sample familiarity from a sample of case studies currently being used in practice. with the authors' own interventions, Partner in Balance and This proposed core business model suggests increasing Myinlife, as the contacted experts belong to the same networks desirability, feasibility, and viability by integrating into larger (such as INTERDEM) and are often exposed to other members' structures; owning and supporting content internally while research. Moreover, the authors acknowledge the potential bias developing ICT services externally; and offering fixed, low-level in reporting the results concerning Myinlife and Partner in pricing. Together with the origin of the case studies, these Balance, as they were involved in their development and elements contributed to the sustainability of case studies. Finally, evaluation. Third, it is likely that more interventions originating targeted digital transformation strategies, more intersectoral from the Southern Netherlands were included (as this is where cooperation, and more financial incentives for research on the authors' research group is based), whereas interventions sustainable business models are recommended to help future from elsewhere in the Netherlands remained underrepresented. developers bring eHealth interventions for caregivers of people A second limitation concerns the potential self-report bias of with dementia into practice. the included case study respondents to emphasize positive

Acknowledgments The authors would like to thank the interview respondents for their time and enthusiasm. The authors would also like to thank Betawerk for their support and advice. The research presented in this paper was carried out as part of the Marie Curie Innovative Training Network action, H2020 Marie Skøodowska-Curie±Innovative Training Network±2015, under grant 676265.

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Conflicts of Interest HLC, LMMB, MEDV, and FRJV were involved in the previous development of Myinlife and Partner in Balance.

Multimedia Appendix 1 Questionnaire. [DOCX File , 14 KB-Multimedia Appendix 1]

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Abbreviations ICT: information and communication technology NVN: Nederlandse Vereniging voor Neuropsychologie (Dutch Association for Neuropsychology)

Edited by J Wang; submitted 06.10.20; peer-reviewed by S Bartels, A Teahan; comments to author 13.11.20; revised version received 12.01.21; accepted 02.02.21; published 03.06.21 Please cite as: Christie HL, Boots LMM, Hermans I, Govers M, Tange HJ, Verhey FRJ, de Vugt M Business Models of eHealth Interventions to Support Informal Caregivers of People With Dementia in the Netherlands: Analysis of Case Studies JMIR Aging 2021;4(2):e24724 URL: https://aging.jmir.org/2021/2/e24724 doi: 10.2196/24724 PMID:

©Hannah Liane Christie, Lizzy Mitzy Maria Boots, Ivo Hermans, Mark Govers, Huibert Johannes Tange, Frans Rochus Josef Verhey, Majolein de Vugt. Originally published in JMIR Aging (https://aging.jmir.org), 03.06.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included.

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